NRSG370 Case Study: Clinical Reasoning Cycle for Connie Brownstone

This case study employs the clinical reasoning cycle to analyze and manage the care of Connie Brownstone, a 79-year-old patient admitted to the ED with severe respiratory distress due to an asthma exacerbation. The study details the initial assessment, including vital signs and physical examination, followed by secondary assessments like arterial blood gas tests and chest X-rays to diagnose acute respiratory alkalosis. Key health problems identified include shortness of breath, wheezing, and heart palpitations. The nursing interventions prioritize dyspnea management with humidified oxygen and bronchodilators, addressing respiratory alkalosis through CO2 aspiration, and managing tachycardia with anti-anxiety medication. The reflection emphasizes the importance of thorough patient assessment and the application of the clinical reasoning cycle in real-world care scenarios, highlighting the role of resources like Desklib in providing solved assignments for students.

Running head: CLINICAL REASONING CASE STUDY
Clinical reasoning case study
Name of the student:
Name of the university:
Author note:

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CLINICAL REASONING CASE STUDY
Nursing is a profession that is associated with various interrelated roles and
responsibilities while assessing a patient, planning care and implementing the care interventions
(Adrogué & Madias, 2014). Often these professional roles and responsibilities overlap and
coincide with each other leading to the errors in the clinical judgment or decision making of the
nurses. Although, there also are considerable decision making framework available for the nurses
to be able to take the correct clinical decisions, and the clinical reasoning cycle is an exceptional
framework (Vincent, Abraham, Kochanek, Moore & Fink, 2017). Clinical reasoning cycle has
been introduced by Tracy Levett Jones, it is a systematic framework that provides the nurses
with a step by step practice model that they can follow to carry out care services adequately
(Levett-Jones, Reid-Searl & Bourgeois, 2018). Thus essay will attempt to explore each of the
step of the clinical reasoning cycle taking the assistance of a case study.
The very first step allows the nursing professional to be able to gain an initial
understanding of the condition that the patient is in and explore the previous medical data
(Levett-Jones, Reid-Searl & Bourgeois, 2018). The patient in the selected case scenario is
Connie Brownstone, a 79 year old patient who was admitted to the ED by her daughter due to
experiencing fluctuating dyspnea which could not be remedied by her regular medication. Now a
respiratory distressed can be due a variety of different causal trajectories and as she had been
triaged in the ED as category 2, as per the Australasian Triage Scale, and brought directly from
the waiting room into a HDU monitored cubicle, it is crucial to undertake several systematic
assessments of the patient to be able to arrive at an accurate diagnosis for Connie. While in the
HDU she also had been provided external oxygen therapy (6L/min) via a Hudson mask, which
indicates at the alarming degree of her respiratory distress (Thomson et al., 2017).

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CLINICAL REASONING CASE STUDY
The first and foremost investigation that is carried out is vital signs which provides key
information about the stability of the patient and any immediate emergencies (Mirhaghi, 2017).
The vital signs of the patient includes RR 35, SpO2 89% (6L oxygen), HR 125bpm, RR 35,
Temp 39.4° Celsius, BP 172/75. The next assessment usually carried in this situations is the head
to toe physical assessment which assesses the posture, consciousness, muscular stability and
auscultating the adventitious breathing sounds and helps in understanding the exact cause of the
respiratory distress in the patient. The information collected in this phase includes evident use of
accessory muscles, bilateral expiratory wheeze, height 145cm, and peak flow as 210 L/min. in
the very next phase the nurse is required to carry out a secondary assessment which is a more
specialized survey and is primarily based on the acute abnormal manifestations or symptoms
exhibited by the patient. As in this case, the patient Connie presented with a respiratory distress,
the secondary survey will be based completely on the respiratory distress, such as FBE test,
arterial blood gas assessment, Urea and electrolyte assessment, blood cultures and chest X-ray
(Flori, Dahmer, Sapru & Quasney, 2015).
While processing the information, the data collected will be interpreted, discriminated,
related, referred and matched to be able to predict the care needs presented by the patient
(Levett-Jones, Reid-Searl & Bourgeois, 2018). In case for Connie, the vital signs indicated
respiratory rate of which is much higher than the normal levels; along with that the oxygen
saturation of the patient is also at 89% indicating low levels of oxygen saturation, which
indicates at severe shortness of breath as a key care problem for the patient. The next most
important investigation for Connie given her signs and symptoms is the arterial blood gas test,
which indicates Connie having pH of 7.48, PaCO2 at 30 and HCO3 at 24. Undoubtedly the
results generated deviate considerably from the normal levels and as per the data, it can be

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CLINICAL REASONING CASE STUDY
clearly deduced that Connie is suffering from acute respiratory alkalosis. The chest X-ray results
indicate at the patient having hyper-expanded lungs which is the most likely cause for the acute
respiratory alkalosis that Connie is suffering from (Kiang et al., 2015).
The key health problems that Connie is experiencing includes:
 Shortness of breath due to acute respiratory alkalosis
 Wheezing due to blocked hyperventilated airways
 Acute respiratory alkalosis caused by hyperventilated airways and alveoli by
aggravated long term asthma (Kiang et al., 2015)
 Discomfort caused due to the hyper-expanded lungs
 Heart palpitation, dizziness and lightheaded-ness due to respiratory distress,
weakness, and decrease in the cerebral blood flow due to lack of sufficient
oxygen intake (Özbek, Divrikoğlu, Yılmaz, Aytaş & Çelik, 2018)
In this case, the most pressing care need of the patient is the shortness of breath which is
alleviating the respiratory rate of the patient to as high as 35/min. hence the first care priority
selected for the patient that needs immediate attention is the shortness of breath. Another
immediate care is the acute respiratory alkalosis that Connie is suffering which is leading to
many other complications for her and can lead to hypocholeremia and hypokapnia further
exacerbating her already distressful condition if adequate care is not taken (Mahler & O'Donnell,
2014). Lastly, tachycardia and heart palpitations is associated with cerebral blood flow reduction
which in turn can lead to cerebrovascular accident. Hence, third most pressing issue for Connie
is the tachycardia and heart palpitation which will require immediate attention.

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CLINICAL REASONING CASE STUDY
With respect to nursing interventions, the first care priority for Connie is Dyspnea for
which she is already provided external oxygen in 6L/min rate, however, in order to accelerate
oxygen saturation the patient can also be provided humidified oxygen. Along with that, the
interventions will also include administration of bronchodilators (Mudd & Sloand, 2015). The
next care need for the patient includes management of respiratory alkalosis so that the patient
regains homeostasis. The interventions that need to implemented includes ausculating breathing
sounds for any signs of complication, the patient also be encouraged for CO2 aspiration
breathing when slightly stable using a brown paper bag so that the blood pH returns to
homeostasis. Electrolyte balance of Connie is needed to be assessed as well to avoid chances or
hypocholeremia or hypokalemia. The tachycardia and palpitation is mainly due to the lack of
adequate cerebral blood flow and related tissue necrosis however it can lead to convulsions,
seizures and even stroke. Although the oxygen therapy will help in enhancing the cerebral blood
flow and improve the palpitation, mild antianxiety medication or sedation medication will relax
the patient and will help her recover (Agerstrand, Burkart, Abrams, Bacchetta & Brodie, 2015).
In this case, the three nursing care priorities selected for the assignment includes
shortness of breath, respiratory alkalosis, and tachycardia along with palpitations. The most
effective interventions which showed marked progress in her condition have been the external
humidified oxygen and bronchodilators. The use of the bronchodilators smoothed the constricted
airways due to the asthma, attack or bronchospasm that she had while the aid of external oxygen
via Hudson mask eased her respiratory distress. The use of CO2 aspiration slowly was successful
in reverting her blood pH back to homeostasis and the aid of sedation and antianxiety pills
helped her calm down which addressed her tachycardia as well (Yeh et al., 2016). Although, I
believe the patient had been complaining of chest tightness in her sleep while mumbling

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CLINICAL REASONING CASE STUDY
although it was very unclear and the nursing supervisor ignored it. I believe if I could have
mustered the courage to cross her and highlight the issue the care could have been more patient
centred and effective for Connie.
On a concluding note, the clinical reasoning cycle serves as a key guidance framework
for nurses engaged in professional practice providing the nurses with the opportunity to learn
from each and every experience of care. In this case, the patient had been suffering from
respiratory alkalosis which stemmed from the exacerbation event of the asthma. This exercise
helped me to understand how to assess the patients that arrive with acute respiratory emergency
and along with that this assignment has also helped me to understand how to implement the steps
of clinical reasoning to the real world care scenario for the patient and implement intervention
successfully.

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CLINICAL REASONING CASE STUDY
References:
Adrogué, H. J., & Madias, N. E. (2014). Respiratory acidosis, respiratory alkalosis, and mixed
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%20respiratory%20alkalosis&f=false
Agerstrand, C. L., Burkart, K. M., Abrams, D. C., Bacchetta, M. D., & Brodie, D. (2015). Blood
conservation in extracorporeal membrane oxygenation for acute respiratory distress
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Flori, H., Dahmer, M. K., Sapru, A., & Quasney, M. W. (2015). Comorbidities and assessment
of severity of pediatric acute respiratory distress syndrome: proceedings from the
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Kiang, T. C., Anthony, Y., Adrian, C. K. W., Sophie, L. T., & Siyue, K. M. (2015). Anxiety,
depression and hyperventilation symptoms in treatment-resistant severe asthma. Clinical
and translational allergy, 5(2), P7. Doi: 10.1186/2045-7022-5-S2-P7

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CLINICAL REASONING CASE STUDY
Levett-Jones, T., Reid-Searl, K., & Bourgeois, S. (2018). The clinical placement: An essential
guide for nursing students. Elsevier Health Sciences. Retrieved from
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%20jones%20clinical%20reasoning%20cycle&f=false
Mahler, D. A., & O'Donnell, D. (2014). Dyspnea: mechanisms, measurement, and management.
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6qEbE74IEkz1mg0AQc737g#v=onepage&q&f=false
Mirhaghi, A. (2017). Vital Sign Assessment Directives Have Not Associated With Diagnostic
Validity. Acta Medica Iranica, 55(6), 414-414. Retrieved from
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%20and%20respiratory%20distress&f=false

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CLINICAL REASONING CASE STUDY
Özbek, A. E., Divrikoğlu, Y. S., Yılmaz, S., Aytaş, N. Ü., & Çelik, E. (2018). Nonsteroidal anti-
inflammatory drug-induced acute respiratory distress syndrome. The American journal of
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Critical Care (7th ed.). St. Louis, Missouri: Elsevier
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(2016). Heart rate variability in major depressive disorder and after antidepressant
treatment with agomelatine and paroxetine: findings from the Taiwan Study of
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